An emergency room doc from Macon and another brewing health care fight

Wednesday is Doctor’s Day at the state Capitol. White coats, stethoscopes, and small containers of hand sanitizer will rule the halls.

The presence of so many physicians will be a good thing, and not just because Georgia’s flu season is the worst seen in a decade. (One senator was sent home earlier this week, to avoid contaminating his colleagues.)

Each passing year, health care becomes a more critical issue in the Capitol — insecurity tends to breed concern.

The January 26, 2018 edition of Georgia Legislative Week in Review with Mark Neisse, Maya Prabhu and the Phrase of the ... read more

Doctors will watch as lawmakers ply their sausage-making trade. Much attention will be paid to Senate Bill 359, a measure to bar “surprise” medical bills sent to patients when they are unknowingly treated by physicians outside their insurance network.

The measure is largely the work of Republican physician-members of the Senate: Chuck Hufstetler of Rome, Dean Burke of Bainbridge, Kay Kirkpatrick of Marietta, Ben Watson of Savannah.

But legislators should likewise keep their eyes peeled for one particular visiting physician: John Rogers, an emergency room doctor from Macon, is already at the forefront of yet another brewing national fight over health care.

Last May, the health insurance giant Anthem – the parent company of Blue Cross Blue Shield – rolled out a new rule for individual policy holders in Georgia and two other states: If you go to the emergency room and it’s not an emergency, you’re going to be stuck with the bill.

The rule went into effect last July 1, and now applies to a total of six states.

The D.C.-based American College of Emergency Physicians has been the loudest critic of the trend. Rogers, co-director of the emergency department at Coliseum Northside Hospital, is in line to become its president next year. He’ll be leading the fight.

“They’re basically saying, ‘You need to know your diagnosis before you go to the [emergency room]. If you’re having chest pains, it better be a heart attack, because if it’s anything else, we’re not going to pay for it,’” Rogers said. “That’s requiring patients, at home, to diagnose themselves. And that’s crazy.”

Rogers, 67, has been an emergency surgeon for 25 years or so. While he’s now in Macon, Rogers said he has done stints in Dublin, Alma, Cordele, and Donalsonville – “all over middle and south Georgia.”

He’s been on the ACEP board since 2011, and is now its chairman. Rogers said he was in Washington in December to meet with Anthem representatives. The talks produced no results.

Anthem/Blue Cross Blue Shield officials insist they need to end the inappropriate use of emergency rooms for patients with non-threatening conditions. Emergency room visits are far more expensive than visits to a doctor’s office or urgent care facility, they contend.

“It’s unclear what they’re trying to accomplish by doing this,” Rogers said. He harkened back to his early days as a surgeon, when he was assured that, if he performed a large number of appendectomies, some of them were sure to be unnecessary.

That was the only way to ensure that everyone who needed an appendix removed, got it removed. Emergency rooms work the same way, Rogers said.

“You want to make sure that everybody who needs to be there, is there. Some of the visits they call unnecessary – I think they’re missing the boat,” Rogers said.

According to the U.S. Centers for Disease Control and Prevention, Rogers said, four percent of visits to emergency rooms are unnecessary. (The insurance industry cites a slightly higher number, about nine percent.)

“My question is, how low is safe? Three percent, two percent?” Rogers asked. “Right now, this is discouraging people that need to go, for financial reasons. It’s really about money,” he said. “They’re delaying care, they’re waiting until they’re sicker, and it’s because of they’re afraid of the financial consequences.”

Rogers say Anthem’s decisions to cover emergency room patients are based on final diagnoses — not the symptoms that patients walk in with. Anthem officials have said that the original symptoms that patients bring with them are being considered , and a statement issued by Blue Cross Blue Shield of Georgia on Tuesday hinted at a policy still being fine-turned:

“Anthem has, and will continue to make, enhancements to our ER program to ensure effective implementation on behalf of our members and customers,” a spokesman wrote us.

But one wonders if the statistically necessary “over-treatment” that Rogers describes – whether applied to appendixes or emergency rooms – is one more thing that must be sacrificed in a health care climate that’s becoming more and more Malthusian.

Rogers said he fears that other major health insurers are poised to follow Anthem’s lead. State Medicaid programs could follow.

The debate has particular implications for Georgia. Blue Cross Blue Shield of Georgia is the only insurer on the Affordable Care Act exchange in many of the state’s 159 counties. Also, emergency room traffic is more important to already beleaguered rural hospitals than major trauma centers such as Grady Memorial Hospital in Atlanta.

Rogers said his group thinks Anthem is violating a federal provision which says if a “prudent layperson” thinks an emergency room visit is required, that should settle the matter.

Anthem says it’s following that standard, but offers few other details.

So it’s unclear where this fight is headed next — to Congress, our Legislature or the courts. For the moment, Rogers said he and his fellow emergency room physicians are collecting stories from ER patients in Georgia and elsewhere – to document exactly what’s happening to whom.

Presumably, some of those stories will be found at the state Capitol on Wednesday.